April 17, 2023

Nobody said the practice of medicine would be easy.  The clinical challenges are difficult enough, but providers must also contend with roadblocks to reimbursement that continue to be placed in their path by expanded rulemaking on the part of federal and commercial payers. 

According to the American Society of Interventional Pain Physicians (ASIPP), five of the seven Medicare administrative contractors (MACs) across the country have adopted a new medical policy—or local coverage determination (LCD)—related to sacroiliac joint (SIJ) injections.  National Government Services (NGS), Cigna Government Services (CGS), Palmetto, WPS, and Noridian have all published new rules for Medicare providers performing SIJ injections within their respective jurisdictions.  Thus far, Medicare contractors Novitas and First Coast have not joined with these five other MACs in publishing this multijurisdictional policy.

The major upshot of these new policies is that they warrant a review to ensure requirements are being met. 

1. Modifier KX.  The LCDs differentiate between diagnostic and therapeutic SIJ procedures.  For diagnostic blocks (either one or two are allowed), claims must include the KX modifier appended to the procedure code.  This is because Medicare only allows four therapeutic SIJ injections per rolling 12 months.  Accordingly, if you don’t append the KX modifier to the diagnostic blocks, Medicare will count that block as therapeutic, thereby allowing you only three additional therapeutic blocks per rolling 12 months.
    
2. Four Blocks Per 12 Months Includes Both 27096 and 64451.  The associated LCD “Billing Article” states that the four therapeutic sessions allowed per rolling 12 months include injections pertaining to the SIJ intraarticular (27096) and the nerves innervating the SIJ (64451).  So, for example, you exhaust your limit with two sessions where 27096 is billed and two sessions where 64451 is billed.  These sessions can be unilateral or bilateral.  So, if you inject the left SIJ in March and the right SIJ in April, that constitutes two sessions.
    
3. The Procedure Report.  Your procedure note must contain the clinical indications for the block and the “pre and post percent of pain relief achieved immediately post-injection.”  It is not sufficient to put this in a follow-up progress note.
    
4. Imaging.  You can use fluoroscopy or CT, but there must be contrast (unless there is a documented allergy or pregnancy, in which case ultrasound can be used).  “Films that adequately document (minimum two views, AP and oblique) final needle position and contrast flow should be retained.”
    
5. Biologics.  These are not allowed as part of the injectant.  Their use could result in a rejection of the claim.
    
6. ASC Claims.  Although physicians will report 27096-50 for bilateral SIJ injections in the ambulatory surgical center (ASC) setting (without billing the fluoroscopy code), the ASC itself must report G0260 LT and G0260 RT, along with the fluoroscopy code 77002.
    
7. Covered Indications.  There are six covered indications, all of which must be met.  These are as follows:
   
   • Moderate pain primarily over the SIJs
   • Three months of LBP
   • Four weeks of conservative therapy
   • Pain below L5 without radiculopathy
   • No other cause of lumbosacral pain
   • Three or more positive findings with provocative maneuvers upon performing six named tests
    
8. Diagnostic Injections.  The patient must have 75 percent relief of pain for the duration of the local anesthetic.  The provider must document the pre-injection pain score on the date of the injection along with the post-procedure pain score on the date of the injection.  In addition, the provider must document the pain score on days following the injection for the duration of the steroid.  The pain scale used must be the same pain scale used at baseline.  You have to name the scales.  Additionally, you cannot just state the percentage of pain relief; you must document “a specific assessment of the duration of relief being consistent or inconsistent with the agent used for the injection” and the date of that assessment.
    
9. Therapeutic Injections.  A 50 percent relief of pain or a 50 percent improvement in ADLs for 3 months are required to continue subsequent injections, using the same pain and ADL scales used at baseline.  Again, you have to name the scales.  If you are using ADLs as the method of continuing therapeutic blocks, you can’t just say there is a 50 percent improvement; there must be a “functional assessment to show clinically meaningful improvement with painful movements and ADLs.”
    
10. RF of SIJ.  Radiofrequency of the SIJ is deemed by the LCDs as not reasonable or necessary and will not be reimbursed.
     
11. Ongoing Rehab Program.  Your progress notes must document that the patient is participating in a rehabilitation program, home exercise program or function restoration program.
     
12. Anesthesia.  Anesthesia for SIJ injections is deemed not medically necessary except in rare cases.
     
13. Other Injections.  The provider may not perform any other types of injections during the same SIJ session.
     
14. Biopsychosocial Rehabilitation.  Patients with coexisting psychological conditions or depression related illness must be stabilized prior SIJ injections.  Multidisciplinary biopsychosocial rehabilitation principles should be provided to these patients.
     
15. Treatment Beyond 12 Months.  Medicare frowns on SIJ injections being carried out beyond 12 months.  However, if you go beyond that period, you must adhere to four requirements: (1) pain is severe enough to cause significant degree of functional or vocational disability, and you have used measurable goals and objective scales to assess the ADL functionality (so, that means you need to perform a baseline ADL functional assessment at the outset); (2) the prior SIJ injections provided 50 percent improvement in pain or ADL functionality; (3) the patient is either a high-risk surgical candidate, does not desire surgery, or the recurrence of pain was relieved for three months by prior SIJ injections, and (4) you must NOTIFY THE PRIMARY CARE physician of the continued use of steroids.

As our readers can see, these new SIJ injection policies are of importance to the chronic pain practitioner.  Accordingly, you will want to review your Medicare contractor’s LCD, including the Billing Article, to further familiarize yourself with all the requirements pertaining to SIJ injections and anesthesia services in connection with these procedures.  Please contact your account executive if you have further questions on this topic.

With best wishes,

Rita Astani
President, Anesthesia